Clinic Registration

Player Information

First Name(*)
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Middle Name
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Last Name(*)
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Date of Birth(*)
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Gender(*)
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Requested Age Group(*)
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Registration Amount Sent
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Medical Insurance Carrier
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Policy Number
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Known Medical Conditions
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Parent/Guardian Contact Information

First Name(*)
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Last Name(*)
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E-mail(*)
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Re-enter Email(*)
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Primary Phone(*)
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Secondary Phone
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Street Address(*)
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City(*)
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State(*)
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Zip(*)
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Parent/Guardian Waiver

I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the US Club Soccer, its affiliated organization and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the US Club Soccer accepting the registrant for its soccer program and activities ("The program"), I hereby release, discharge and otherwise indemnify the US Club Soccer, its affiliated organizations, their associated personnel, including the owners of the fields and facilities utilized for the program against any claims by or on behalf of the registrant as a result of the registrant's participation in Club sponsored clinics or camps.

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